more_vertThis report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities.
Preference: General Practice and Primary Care
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Steadfast support
BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE
As 2018 rushes to a close I want to reflect on some of the AMA’s activities this year in supporting GPs in their role as the primary provider of medical care. The primacy of the role that the usual GP and their general practice plays in a patient’s health care is something that the AMA steadfastly defends. Throughout this year we have strongly advocated for an improvement to GP funding to sustain and nourish general practice in effectively delivering patient-centred quality care and in meeting the health care needs of the community.
GP services are in high demand as the population ages, complex and chronic disease become more prevalent, and poor lifestyle choices add to the risk for and burden of disease. Yet, general practice is the most efficient and cost-effective part of Australia’s health system. Given the increasing cost pressures general practices have experienced over the years, this is a true testament to the general practice profession.
While the Federal Budget this year made some down-payments towards improving GP funding, much more is required to support our vision for general practice into the future. A vision that involves general practice being supported as its patients’ medical home and that strengthens and supports team-based care. A vision that involves GPs being rewarded for the non-face-to-face work involved in caring for patients, that enables better access to quality GP care to patients in aged care facilities and at home, that supports greater use of technology to enhance access to care and its continuity and delivery. A vision that ensures quality improvement is supported and rewarded.
The Government must invest, and invest significantly, to make this vision a reality.
This is a message that AMA leadership and advocacy has continually impressed upon key politicians and around Commonwealth departmental meeting tables throughout the year.
Our proposal and advocacy for the integration of non-dispensing pharmacists into general practice to enhance medication management resulted in incentive reforms that will see practices further supported to build their practice-based health care teams. From July 1 2019, the Workforce Incentive Program will see the provisions of the Practice Nurse Incentive Program expanded to include non-dispensing pharmacists and allied health providers for all eligible general practices regardless of location.
While the MBS Review process has had its issues, when it comes to general practice and primary care the AMA is optimistic that our message around improved rebates, the centrality of the GP to the health system and to patient care has resonated. The AMA is keen to see the recommendations of the MBS Review Taskforce in this space support longitudinal care, patient centred and multi-disciplinary care, and provide for enhanced access via telehealth services.
Finally, the AMA, through a number of submissions, in our discussions and representations, has worked hard to convey the risks to patient care and health system expenditure of moves that would fragment primary care. Proposals for inappropriate expansions of scopes of practice, prescribing rights, and models of care that would see skilled GPs excluded from elements of the cradle to grave care they provide have been and will continue to be stridently argued against.
The coming year, I’m sure, will provide many more opportunities for the AMA to advocate for and support general practice.
In the meantime I wish you all safe and happy holidays.
Preventing heart disease – a continuing story
BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY
Public Health England (PHE) is the organisation responsible for the oversight of all preventive activity in England. This ranges from vigilance for infectious disease outbreaks and epidemics, through immunisation programs, to advice and support for prevention in general practice – including that relating to non-communicable diseases, especially circulatory disorders.
With the increased prevalence of cardiovascular disease in an ageing population, PHE has been reviewing investment in its prevention strategy. (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/749866/CVD_ROI_tool_final_report.pdf)
As in Australia, since the mid-1960s, deaths in middle age from heart attack have decreased in England by well over 50 per cent. This is attributable, almost equally as best we can tell, to improvements due to primary prevention, most notably dramatic downturns in smoking, and to improved treatment.
Falls in the rate of ‘sudden death’, which are substantial, are an obvious place where primary prevention is working. But the evidence is difficult to collect and assess. As Earl Ford, an American epidemiologist, and Simon Capewell, a clinical epidemiologist from Liverpool University in the UK, wrote in 2011 (www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031210-101211), “Changes in risk factors may explain approximately from 44 per cent to 76 per cent of declining CHD mortality and treatments may explain approximately from 23 per cent to 47 per cent. Thus, both prevention and treatments have contributed immensely to the decline in CHD mortality.”
Nevertheless, despite these advances, cardiovascular disease remains a major problem. This year, according to calculations from the Australian Heart Foundation, based on data from the Bureau of Statistics, about 8,000 Australians will die from a heart attack.
Heart attack death was previously restricted to economically advanced societies, but it now spread widely through economically developing, and even the poorest, nations. Here, death from heart disease follows the pattern we saw in Australia before the decline in mortality began in the 1960s, namely, middle-aged men and women, rather than the elderly, being at serious risk. Our effectiveness in managing infectious disease in those less affluent countries means that those people are now more prone to the degenerative diseases familiar to us.
What is the scope for prevention in clinical practice? A survey this year by the Heart Foundation found: “One in two Australians who have had a heart attack [and there are about 40,000 of them under 55] continue to smoke. Of these, close to 40 per cent did not even attempt to quit … almost one in four have failed to regularly monitor their blood pressure levels. More than a quarter are not having regular cholesterol checks. Around one in three tried to increase their physical activity levels or lose weight, however failed to maintain the changes.”
In clinical practice, prevention of death – and disability – from cardiovascular disease is a deep concern –a frequent reason for consultation and prescription and a major consumer of time in general practice.
Despite the lack of information about outcomes, Public Health England, with help from the University of Sheffield, examined the available evidence for what works and how much it costs (including general practitioners’ time). PHE settled on five interventions – detection and treatment which had merit both in terms of medical outcome and cost for:
- Hypertension
- Atrial fibrillation (anticoagulation)
- Hypercholesterolaemia
- Diabetes
- Non-diabetic hyperglycaemia (‘pre-diabetes’)
- Chronic kidney disease.
Based on a 2014 health survey in England, the prevalence of individuals aged 16+ with one or more of these high risk conditions was 49 per cent.
The best evidence concerning effective interventions for each condition was then assembled, along with data on the cost of the most effective interventions and the duration of likely effect following the interventions. This information was combined into a package which allows individual practitioners to calculate the local costs and benefits of these interventions in their practice.
“The single intervention with the highest net total savings in the short term (years 2-5) is to optimise the proportion of people taking statins… a saving of £700 million in England [total population: 45 million] by year five. However, in the long term (20 years), optimising antihypertensive treatment is the single intervention predicted to save the most money (over £2 billion)… but most of the lifestyle interventions are not cost-saving over 20 years.”
What may we conclude for Australia? Among the preventive interventions for managing cardiovascular disease in general, and heart disease in particular, we are committed to long-term care for optimal effect. This may not become obvious for 20 years, but this is not to gainsay it.
Preventive treatment requires a philosophy of long-term care and support to be effective.
IT IS MEMBERSHIP RENEWAL TIME
Thank you for being an AMA member. Your membership keeps us strong.
There will be a Federal Election in 2019. Health policy will help determine the next Government.
Your AMA will be advocating for:
- Significant new investment in general practice
- MBS review outcomes that improve the delivery of health care
- Increased public hospital funding
- National Mandatory Reporting laws that help doctors and patients
- Better value and more transparent private health insurance
- A My Health Record that protects patient privacy and confidentiality
- Better health care for asylum seekers and refugees
- A greater focus on mental health
- Urgent action on aged care reform
- Strategic funding and programs to improve Indigenous health
- A reinvigorated approach to public health and prevention
- Cohesive medical workforce and training policies across all governments
The AMA is the only organisation that can cover the depth and breadth of health policy across the Federal, State/Territory, and local levels. The AMA is your partner to influence and improve health policy, and to provide advice and resources to support you in your practice and career.
The AMA is the voice of the medical profession and the voice of the patients in our care. The AMA is your voice.
Simply renew your tax-deductible membership online or contact your local AMA office.
AMA tells Canberra that obstetricians must lead maternity services
The AMA insists that national maternity services must use a collaborative care model that is led by obstetricians or general practice obstetricians.
It has said exactly that in its submission to the Commonwealth Department of Health and Ageing on the proposed new National Maternity Services Strategy.
AMA President Dr Tony Bartone said best-practice maternity care in the 21st century is provided by a multi-disciplinary team of health professionals.
“Obstetricians are the leaders and, along with midwives, are the key carers, but the team also includes general practitioners, anaesthetists, psychiatrists, obstetric physicians, pathologists, haematologists, paediatricians, and nurses,” Dr Bartone said.
“Current evidence supports that this model of care – led by an obstetrician or GP obstetrician – is the safest for mothers and babies, and optimises a range of other health outcomes.
“Obstetrician-led or GP obstetrician-led care means that, at a minimum, there will be initial assessment by either an obstetrician or GP obstetrician, and assessment and regular review during labour.
“Models of care should not result in situations where obstetricians only become aware of a labour problem once it has become acute or serious.
“Women should be encouraged and supported to make their own choices about their maternity care.
“But they should be fully informed about the risks and benefits of each model as it relates to their own specific health situation, pregnancy, and circumstances, after assessment by an obstetrician or GP obstetrician.
“In many instances, GPs are the health professionals who start the conversation with women about having children.
“GPs are best placed to provide continuity of care for women before, during, and after their pregnancies.
“And GPs are especially important in providing whole of maternity care for women in rural and remote communities.”
Dr Bartone said significant additional Federal Government funding will be needed to ensure safe, high-quality, and easily accessible maternity services across Australia.
The AMA used the following principles to assess the draft strategy:
- The primary objective of all maternity services should be healthy mothers and babies.
- Ideology and practitioner-specific agendas should not determine maternity policies and services.
- Policies and services should be evidence-based.
- Policies and services should consider the woman, her baby, and family.
- Funding should follow models of care which improve the health and survival of mothers and babies, are cost effective, and improve women’s experiences.
[Department of Error] Department of Error
Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries Lancet 2018; https://doi.org/10.1016/S0140-6736(18)31668-4—In figure 2 of this Article (published Online First on Sept 5, 2018), the y axis should read “deaths in 100 000s”. The affiliation for Prof Salomon should read “Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA”.
Your AMA Federal Council at work
Dr Innes Rio AMA Member Health Expert Advisory Group 18/09/18
Dr Tony Bartone, Dr Richard Kidd AMA President, AMACGP Chair Senate Inquiry into Aged Care Quality and Safety Commission Bill 2018 and related Bills 10/10/2018
Dr Simon Torvaldsen, Dr Kean-Seng Lim Chair, AMA WA Council of General Practice, AMA NSW President House of Representatives Inquiry into Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 26/10/2018
Professor Mark Khangure Federal Councillor – specialty member – radiologist Australian Digital Health Agency – diagnostic imaging sector interoperability workshop 8/10/2018
Dr Danielle McMullen AMACGP member/NSW AMA Vice-President TGA stakeholder meeting on opioid regulation 29/10/2018
Issues to be aware of when responding to compliance audits
BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE
The Department of Health regularly conducts compliance audits of practitioners to ensure that the amounts claimed under the Medicare Benefits Schedule (MBS) are correct. I thought it might be beneficial to provide you with some information about the Department’s processes, your obligations and options when responding to an audit. The AMA’s Legal Counsel has assisted me in this to ensure you understand the process and are equipped to respond to any compliance concerns that may arise while still protecting patient privacy.
When conducting an audit, the Department’s general approach is to:
(1) identify the practitioners to be targeted in the audit. This could be through tip offs or data analysis;
(2) send the identified practitioners a letter asking them to verify their compliance; and
(3) depending on the audit target’s response, issue a Notice to Produce under section 129AAD of the Health Insurance Act 1973.
The following looks at the privacy and other issues that GPs and general practice managers need to be aware of at each stage of the process.
Initial letter
The initial letter will usually advise the practitioner of the concern that has given rise to the compliance action; and ask them to provide evidence that they have met the requirements of the items being audited. This evidence is usually in the form of some documentation.
Practitioners should note that this letter is asking practitioners to voluntarily:
- provide documentation to support their claims; or
- acknowledge where they have not fully met the requirement of the item claimed and thus have been overpaid.
Practitioners need to be mindful of protecting patient privacy when voluntarily providing documentation to support their claims. The sections below have more information on why and how.
Practitioners who think they may have claimed inappropriately may avoid an administrative penalty if they voluntarily acknowledge their error and the overpayment of benefits. Where the Department has already sent an initial letter, the maximum reduction of the administrative penalty is 50 per cent. Any overpayments plus any applicable penalty will then be raised as debt owing for repayment.
Notice to Produce
Depending on the outcome of the initial letter, the Department may issue a Notice to Produce.
A practitioner can still receive a reduction in the administrative penalty after a Notice to Produce is issued, if they voluntarily acknowledge the overpayment before the time to respond to the Notice to Produce expires. However, the maximum reduction is lower (25 per cent) than if the practitioner had acknowledged the error prior to receiving the Notice to Produce.
Practitioners will have at least 21 days to respond before the Notice to Produce expires and a debt for the claims in question is raised.
Privacy issues
Australian Privacy Principle 6 prohibits practitioners from disclosing their patient’s records unless an exception applies. A key exception is where disclosure is ‘required or authorised by law’ (APP 6.2).
A practitioner is legally required to comply with a Notice to Produce. This means that a practitioner will not be breaching the Privacy Act if they provide patient information in response to a Notice to Produce. However:
- practitioners should only provide patient information to the extent necessary to comply with the Notice to Produce; and
- the AMA recommends that practitioners exercise their statutory right to only provide documentation containing ‘clinical details relating to an individual’ to a departmental medical adviser.
By contrast, a practitioner may breach the Privacy Act if they provide any documentation containing health information prior to the Department issuing a Notice to Produce. This is because practitioners are not legally required to respond to the initial letter. This means that practitioners:
- should not volunteer any patient information at the initial letter stage; and
- if they do choose to respond, must redact enough personal information to protect the privacy of the patient.
So why does the Department send initial letters?
Part of the reason why the Department sends initial letters is that voluntary compliance avoids more expensive and difficult compliance processes.
The other reason is that section 129AAD of the Health Insurance Act provides that the CEO Medicare must give practitioners an opportunity to respond to a request for documents before they issue a Notice to Produce. In other words, they must ask you to provide supporting documentation even though it is not mandatory for you to do so, and if you do and that documentation contains patient information you will be breaching the Privacy Act, before they can issue a binding Notice to Produce, which then protects you under the Privacy Act for providing the information.
Other consequences of voluntary repayments
The AMA appreciates that practitioners may choose to voluntarily acknowledge an overpayment to avoid the administrative costs of locating records to prove their claims were legitimate. However, practitioners should be aware that if they voluntarily acknowledge an overpayment, any associated incentive payments claimed in conjunction with the payments for services that have been voluntarily acknowledged will also be recoverable.
The Department of Health also discourages practitioners from voluntarily acknowledging “no service” when a service was provided because of the flow on impacts on the patient’s My Health Record and MBS claim history.
Accordingly, it is recommended that practitioners consult with their medical defence organisation before responding or submitting any documentation to the Department to ensure they are aware and understand the financial and legal consequences.
One in four Australians are lonely: research
The most comprehensive report on loneliness in Australia has revealed that a quarter of adults are lonely for three or more days of the week, and this has significant implications for their mental and physical health.
The Australian Loneliness Report, released by the Australian Psychological Society and Swinburne University, also found that one in two (50.5 per cent) Australians feels lonely for at least one day in a week, while more than one-fifth of people rarely or never feel they have someone to talk to or turn to for help.
These results come from an online survey completed by 1,678 people from across Australia between 29 May and 1 October 2018. The survey continues to be run by Swinburne University to track loneliness levels over time.
As part of the research. loneliness was measured using the UCLA Loneliness Scale, a comprehensive gold standard measure of loneliness, with a range from 20-80 with higher scores indicating a higher level of loneliness.
Dr Michelle Lim, senior lecturer and clinical psychologist from Swinburne University of Technology told doctorportal that “loneliness matters as it affects our health and the social fabric of our community – there may be evidence that it affects workplace productivity.”
Lonely Australians have significantly worse mental and physical health.
The report found that lonely Australians are 15.2% more likely to be depressed and 13.1% more likely to be anxious about social interactions than those who are not lonely.
Higher levels of loneliness are also associated with less social interaction, poorer psychological well-being and poorer quality of life.
Previous research has established that loneliness increases the likelihood of an earlier death by 26%. High levels of loneliness are associated with poorer overall physical health, increased number of headaches, poor sleep and worse experience of physical pain.
Loneliness did not discriminate significantly by age. The oldest Australians (over 65 years) were the least lonely, while there were no differences in loneliness levels between other age groups. Younger adults reported significantly more social interaction anxiety than older adults.
What causes loneliness and how can we address it?
Dr Lim said that while the specific causes of loneliness are unknown at present, there are correlates of loneliness that can be measured, such as marital status or living alone, which indicates these may influence loneliness.
The report found that Australians who are married are the least lonely compared to those who are single, separated or divorced. Australians in a de facto relationship are also less lonely than those who are not.
Dr Lim said that at present, service providers encountering loneliness do not have any guidance or training to assist with it, and there continues to be a lack of awareness of the consequences of loneliness.
“Educating and normalising loneliness as a normal human condition is the first step.”
Dr Lim said that in particular, “we need guidelines, for example for first responders on how to deal with lonely people who present at health services”. These guidelines must outline where a lonely person can go for support and highlight the kind of resources that will be made available to that person.
She said that strategies also needed to be developed and implemented to encourage people experiencing loneliness to make more meaningful connections.
Being heart smart could prevent cognitive decline in women
New research has revealed that cardiovascular risk factors, particularly high cholesterol, play a role in the development of cognitive decline, further highlighting the importance of kickstarting healthy heart habits earlier in life.
Professor Cassandra Szoeke, director of the Healthy Ageing Program at the University of Melbourne and lead researcher, said the results showed that strategies to target vascular damage are vital to prevent brain cell loss.
“Neurodegenerative brain disease works insidiously for decades before people are diagnosed with dementia – we need to stop it in its tracks, or ideally before it starts.”
“What you do now affects what you will be decades later.”
What did the study involve?
The Australian study, published in Brain Imaging and Behaviour, included 135 participants from the Women’s Healthy Ageing Project. These women had completed midlife cardiovascular risk measurement in 1992, followed by an MRI scan and cognitive assessment in 2012.
The researchers found that higher midlife Framingham Cardiovascular Risk Profile (FCRP) score was associated with greater White Matter Hyperintensity (WMH) volume two decades later, and was predominantly driven by the impact of HDL cholesterol level.
Structural equation modelling demonstrated that the relationship between midlife FCRP score and late-life executive function was mediated by WMH volume.
“We saw those with low brain volume lost even more volume over the next 10 years,” Professor Szoeke said.
The authors wrote that their results indicated that intervention strategies targeting major cardiovascular risk factors at midlife might be effective in reducing the development of WMH lesions and thus late-life cognitive decline.
Massive exercise changes aren’t needed – but being active every day is key
“We all know we should eat healthily and exercise, but we also know many people who start up a program are not participating 3 months later, and 12 months later even less are still participating,” Professor Szoeke said.
Going into the study, her research team had expected that women who did intense physical activity would have the best cognition down the track.
“We found it was those who did activity every day over the 20 years of follow-up. It could be walking the block or gardening or a mix of Saturday dancing, Sunday walking home, and Monday walking to work – but it is each and every day for 20 years.”
Professor Szoeke said the impact of the research should be a greater recognition that vascular risk is modifiable, If it’s left unchanged, this will lead to brain damage in the form of WMH, low brain volume and poor cognition.
She said modifying this risk doesn’t mean a huge lifestyle change. In fact, the benefit can be obtained from just being more active.
“Move often and eat healthily. Choose what works for you, change it as you need, and do it each and every day.”
Women are disproportionately affected by dementia
Women account for around two-thirds of all dementia cases. Understanding the reasons behind this is an issue close to Professor Szoeke’s heart.
She said while women generally live 3 to 4 years more than men, it is not just an effect of age. The fact that the symptoms, assessment, treatment, management and prevention of heart disease differs between men and women suggested that cardiovascular risk also plays a role.
“Last year, the Australian Hidden Hearts report was released, showing that women have more heart disease, heart failure and stroke than men,” Professor Szoeke said.
“The Health Minister Greg Hunt has announced an update of women’s health policy. There has been $18 million announced for research to fill these gaps in knowledge, particularly highlighting issues not often focused on in traditional women’s health.”
She said the strategic areas for the new update reflect key issues for women, including mental health, dementia, chronic disease and healthy ageing.
“I hope we can quickly see major improvements with investment in these areas.”